Centering Anti-Racism and Social Justice in Nephrology Education to Advance Kidney Health Equity
Authors: Tanjala S. Purnell, O. N. Ray Bignall, Keith C. Norris
Journal: Journal of the American Society of Nephrology (2022)

"The function of education is to teach one to think intensively and to think critically. Intelligence plus character—that is the goal of true education." (Rev. Dr. Martin Luther King, Jr.) To advance kidney health equity, it is critical to train kidney care providers and researchers in skills that are important to achieving health equity. To accomplish this, we must first re-evaluate the extent to which antiracism, health equity, and social justice are centered in nephrology education. Preparing a new generation of nephrology thought leaders who understand the roles of structural racism and structural drivers/social determinants of health (SDOH) in perpetuating racial disparities is paramount to designing, implementing, and sustaining efforts that promote kidney health equity.1 Structural racism is a complex, often subtle form of racism that is pervasive and permeates the fabric of society, and is defined as mechanisms by which societies foster racial discrimination through systems of employment, housing, education, income, healthcare, criminal justice, and more that reinforce discriminatory beliefs, values, and distribution of resources and opportunities.23–4 Within the context of kidney care and outcomes, structural racism may manifest as racial disparities in the SDOH (e.g., education, wealth, housing, or employment), healthcare access and quality measures, inappropriate use of race in healthcare decisions, patient engagement in care, and implicit and explicit provider biases.34567–8 A central focus of centering health equity in nephrology education involves achieving a comprehensive understanding of how health systems/organizations, providers and staff, patients and families, and social factors operate interdependently (either consciously or unconsciously) to influence kidney care and health outcomes. As illustrated in Figure 1, health system and organizational factors include both human factors (e.g., implicit and explicit biases, organizational climate, and workforce policies) and structural factors (e.g., shared treatment decision-making tools, language services, reimbursement policies).9 Provider and staff factors include health equity training and expertise, cultural and social skills and behaviors, and abilities to deliver high-quality care to a diverse group of patients.8 Patient and family factors include lived experiences of racism and discrimination, healthcare access and quality of care, and social support.9 Patient experiences of care may also vary according to several social measures, including race, ethnicity, and culture; socioeconomic position; education; sex; religion; social relationships; and community context.9 Collectively, healthcare factors and social factors influence kidney care and outcomes, including patient activation and engagement, experiences of care, shared treatment decisions, and lifestyle and self-care behaviors.Figure 1.: Conceptual model of how kidney care factors and social factors may influence kidney health outcomes. Adapted from ref. 9, with permission.Centering Antiracism and Social Justice in Nephrology Education We offer several recommendations for centering antiracism and social justice in nephrology education to advance kidney health equity (Table 1). In the presence of racially biased structured and systems people can choose to further promote them (racist action), do nothing (non-racist action) or attempt to dismantle (antiracist action), and only antiracism can move us toward health equity in this setting. So first, we must officially acknowledge and adopt evidence-based strategies to address implicit biases and explicit acts of interpersonal racism in healthcare encounters that may perpetuate kidney health disparities. Second, we must work to eliminate structural racism at the societal and health system levels that systematically introduce inequities in kidney care. Specific examples may include adopting new policies and practices that mitigate the detrimental effects of subjective and potentially biased clinical decisions, policies, and practices.3456–7 Table 1. - Key recommendations for centering antiracism and social justice in nephrology education to advance kidney health equity Number Key Recommendations 1 Officially acknowledge and adopt evidence-based strategies to address implicit biases and explicit acts of interpersonal racism in healthcare encounters 2 Work to eliminate structural racism at the societal and health system levels, which include subjective and potentially biased decisions, policies, and practices 3 Incorporate health equity research training inclusive of key methodologic and content areas 4 Foster role modeling through faculty mentorship and professional networking opportunities 5 Model best practices for developing and sustaining community partnerships and coordinated advocacy efforts to address the SDOH that influence kidney care Standardized educational content about the influence of structural racism in kidney health research, and strategies to address it, should also be developed and adopted. This includes recognizing the presence of implicit biases within each of us that may influence the framing of research questions, the creation of many of the study measures/surveys we design and implement, and the lens through which we analyze and interpret results. Identifying and adopting best practices for collaborative team care, involving nephrologists, primary care providers, social workers, patient and community advocates, peer navigators, and healthcare equity experts, are also vital approaches to fostering respect for individuals and groups, creating a deeper sense of shared humanity for overcoming racialized narratives, and mitigating structural barriers that perpetuate kidney health disparities. Within Table 2, we have included an example curriculum and available resources to assist nephrology program directors in centering antiracism, social justice, and health equity research in nephrology education. We recommend inclusion of this important content within established nephrology weekly seminar series, grand round talks, and through completion of Coursera online short courses with rolling admissions that may be completed as time permits.10 Table 2. - Example curriculum for centering antiracism, social justice, and health equity research in nephrology education Curriculum Topic Format Resource Understanding social justice, race, and racism • A social justice/equity orientation Nephrology seminars ASN Anti-Racism Toolkit (https://www.asn-online.org/education/training/tpd/hjc-toolkit/) • Understand race, racism, and chronic kidney disease (CKD) health • Differentiating race, genetics, and ancestry • Review the social determinants/structural drivers of CKD burden and outcomes • Race and ethnicity in scientific peer review and publication practices • Appropriate use of race in clinical and epidemiologic studies (including quantitative critical race theory) Race, antiracism, and intersectionality in CKD • Community partnering as antiracist/decolonizing approach to equity Nephrology grand rounds Invited National Experts in CKD Health Equity • Understand the role of race in clinical care of patients with CKD • Intersectionality of race and other social identities • The effect of structural racism on children with CKD and their families • History of medical racism and implications for CKD care • Prioritizing health equity in quality improvement efforts in CKD • The way forward: Discuss the difference between equity-focused race consciousness and race-blind views Foundations of health equity research • Introduction to health equity research methods Coursera online short course (open to public) https://www.coursera.org/learn/health-equity-research • Engaging community stakeholders in health equity research • Engaging policymakers to address SDOH • Engaging health system leaders and organizational stakeholders • Using digital and social media to engage stakeholders and disseminate health equity research Application of health equity research methods for practice and policy • Designing multilevel interventions to close the implementation gap Coursera online short course (open to public) https://www.coursera.org/learn/health-equity-research-methods • Using social epidemiology research to inform interventions • Using health services research to inform health equity interventions • Tailoring assessment and intervention materials for at-risk groups • Community- and stakeholder-engaged health equity research approaches • Best practices for implementing health equity research The third recommendation is to incorporate research training inclusive of methodologic and content areas that are vital to health equity. Key methods include social epidemiology, health services research, qualitative and quantitative research methods, health policy, community-based participatory research, bioethics, clinical trials, behavioral interventions, and implementation science through a social justice lens. This should also include the appropriate recognition and thoughtful use of race and ethnicity as latent variables often used to represent social group membership and shared characteristics, but not individual-level health proxies, because they are nominal (i.e., have no intrinsic ordering to assigned categories), with no direct relation to any health outcome or any biomarker proxy.6 Advanced training in these methodologic areas, combined with content knowledge related to addressing the SDOH, and risk factors influencing renal disease disparities are important to advance equity. Kidney research investigators should also appropriately acknowledge and examine the role of racism in perpetuating racial disparities and propose and conduct rigorous study designs that move beyond just a basic description of differences in healthcare access and outcomes by race. We should strive to incorporate nuanced discussion of the role of racism in perpetuating racial disparities and potential recommendations for needed next steps to advance equity. Our final recommendation is to foster role modeling within nephrology education through faculty mentorship and professional networking opportunities. This involves active mentorship from nephrology and other professional mentors who are experts in health equity, antiracism, and/or social justice practices. Role modeling is important for fostering best practices in kidney care and research, recruiting and training diverse professionals who are primed to become leaders in the field, and applying social justice principles in policy and practice. It is also important to actively provide mentoring and sponsorship opportunities for trainees and junior investigators who are committed to kidney health equity, antiracism, and social justice work, including appropriate nominations for invited talks, media opportunities, podium presentations at national meetings, and inclusion on grant applications and manuscripts. Further, it is critical to model best practices for developing and sustaining community partnerships and coordinated advocacy efforts to address the SDOH that influence kidney care and outcomes. Key partnerships involving kidney care providers, patients, community organizations, professional societies, researchers, and policy makers are needed to champion kidney health equity. Conclusion Racial inequities in kidney care and outcomes have long been documented. As nephrology professionals, it is our collective duty to educate one another on the influence of racism on these inequities, and how we can work together to mitigate racism's effect. We can achieve this goal together by acknowledging the influence of systemic racism on kidney care and research, dismantling the institutionally racist systems around us, intentionally incorporating antiracist educational curricula into nephrology training programs, and promoting kidney health professionals as leaders and role models of kidney health equity and antiracism. To effectively advance kidney research and practice beyond simply describing disparities to the creation of sustainable solutions that eradicate them, we must train a prepared nephrology workforce that centers antiracism and social justice in sustained efforts to advance kidney health equity. Disclosures O.N.R. Bignall II reports being the chair of the ASN Health Care Justice Committee and colead of the Education Workgroup. K.C. Norris reports having other interests or relationships with American Association of Kidney Patients (AAKP), ASN, ESRD Network Forum, NKF, and Society of General Internal Medicine; serving in an advisory or leadership role for AAKP, Association of American Medical Colleges, Atlantis Healthcare, CJASN, ESRD Network Forum, Ethnicity and Disease, International Society of Nephrology, JASN, National Kidney Foundation's (NKF) Kidney Early Evaluation Program, and National Institute of Diabetes and Digestive and Kidney Diseases Council; being a member of the ASN Health Care Justice Committee Education Workgroup and a member of the editorial boards of CJASN and JASN; having consultancy agreements with Atlantis Healthcare (compliance, research, and quality care for dialysis and CKD care in Puerto Rico); and receiving research funding from the National Institutes of Health (NIH) and the state of California. T.S. Purnell reports serving as the chair of the American Society of Transplant Surgeons (ASTS) Diversity, Equity, and Inclusion Committee; the colead of the Education Workgroup for the ASN Health Care Justice Committee; a member of the board of directors for the National Minority Organ Tissue Transplant Education Program (MOTTEP); and for The Living Legacy Foundation of Maryland. Funding T.S. Purnell was supported by the Agency for Healthcare Research and Quality (AHRQ) grant K01HS024600. K.C. Norris was supported by NIH grants UL1TR000124, P30AG021684, and P50MD017366.